eNursing Care Plan 34-1

Patient with Heart Failure

Nursing Diagnosis*
Impaired Gas Exchange
Etiology: Increased preload, alveolar-capillary membrane changes
Supporting data: Abnormal O2 saturation, hypoxemia, dyspnea, tachypnea, tachycardia,
restlessness, patient’s statement, “I am so short of breath”

Patient Goal
Maintains adequate O2/CO2 exchange at the alveolar-capillary membrane to meet O2
needs of the body

Outcomes (NOC) Interventions (NIC) and Rationales

Respiratory Status: Gas
Exchange
 O2 saturation ___
 Arterial pH ___
 PaO2 ___
 PaCO2 ___
 Chest x-ray findings ___
Measurement Scale
1 = Severe deviation from
normal range
2 = Substantial deviation from
normal range
3 = Moderate deviation from
normal range
4 = Mild deviation from normal
range
5 = No deviation from normal
range
 Dyspnea with exertion ___
 Dyspnea at rest ___
 Restlessness ___
 Impaired cognition ___
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
Respiratory Monitoring
 Monitor pulse oximetry, respiratory rate, rhythm,
depth, and effort of respirations to detect changes in
respiratory status.
 Auscultate breath sounds, noting areas of decreased or
absent ventilation and presence of adventitious sounds
to detect presence of pulmonary edema.
 Monitor for increased restlessness, anxiety, and work
of breathing to detect increasing hypoxemia.
Oxygen Therapy
 Administer supplemental O2 or other noninvasive
ventilator support (e.g., bilevel positive airway
pressure [BiPAP]) as needed to maintain adequate O2
levels.
 Monitor the O2 liter flow rate and placement of O2
delivery device to ensure O2 is adequately delivered.
 Change O2 delivery device from mask to nasal prongs
during meals as tolerated to sustain O2 levels while
eating.
 Monitor the effectiveness of O2 therapy to identify
hypoxemia and establish range of O2 saturation.
Positioning
 Position patient to alleviate dyspnea (e.g., semi-
Fowler’s position), as appropriate, to improve
ventilation by decreasing venous return to the heart
and increasing thoracic capacity.

*Nursing diagnoses are listed in order of priority.

Copyright © 2020 by Elsevier, Inc. All rights reserved.

eNursing Care Plan 34-2

Outcomes (NOC) Interventions (NIC) and Rationales

5 = None

Nursing Diagnosis
Impaired Cardiac Output
Etiology: Altered contractility, altered preload, altered stroke volume
Supporting data: Decreased ejection fraction, increased CVP, decreased peripheral
pulses, jugular venous distention, orthopnea, chest pain, S 3 and S4 sounds, oliguria

Patient Goal
Maintains adequate blood pumped by the heart to meet metabolic demands of the body

Outcomes (NOC) Interventions (NIC) and Rationales

Cardiac Pump Effectiveness
 Ejection fraction ___
 Systolic BP ___
 Diastolic BP ___
 Apical heart rate ___
 24-hr I/O balance ___
 CVP ___
 Peripheral pulses ___
Measurement Scale
1 = Severe deviation from
normal range
2 = Substantial deviation from
normal range
3 = Moderate deviation from
normal range
4 = Mild deviation from normal
range
5 = No deviation from normal
range
 Neck vein distention ___
 Abnormal heart sounds ___
 Dysrhythmia ___
 Dyspnea ___
 Peripheral edema ___
 Pulmonary edema ___
Cardiac Care
 Perform a comprehensive assessment of peripheral
circulation (e.g., check peripheral pulses, edema,
capillary refill, color, and temperature of extremity) to
determine circulatory status.
 Note signs and symptoms of decreased cardiac output
(e.g., chest pain, S3, S4, jugular venous distention) to
detect changes in status.
 Monitor fluid balance (e.g., I/O and daily weight) to
evaluate patient’s fluid status.
 Monitor cardiac rhythm to detect dysrhythmias.
 Monitor respiratory status for symptoms of heart
failure (e.g., dyspnea, fatigue, tachypnea, orthopnea) to
identify involvement of respiratory system.
 Teach patient and caregivers on activity restriction and
progression to allay fears and anxiety.
 Establish a supportive relationship with the patient and
caregiver(s) to promote adherence to the treatment
plan.
 Teach the patient of the purpose for and benefits of the
prescribed activity and exercise to enhance adherence.

Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None

Copyright © 2020 by Elsevier, Inc. All rights reserved.

eNursing Care Plan 34-3

Nursing Diagnosis

Fluid Imbalance
Etiology: Increased venous pressure, decreased renal perfusion secondary to heart failure
Supporting data: Rapid weight gain, edema, adventitious breath sounds, oliguria,
patient’s statement, “My ankles are so swollen”

Patient Goal
Has reduction or absence of edema and stable baseline weight

Outcomes (NOC) Interventions (NIC) and Rationales

Fluid Balance
 Stable body weight ___
 Peripheral pulses ___
 Serum electrolytes ___
 BP ____________
 CVP ___
 24-hr I/O balance ___
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
 Ascites ___
 Neck vein distention ___
 Peripheral edema ___
 Adventitious breath sounds
___
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None
Hypervolemia Management
 Administer prescribed medications to reduce preload
(e.g., furosemide, spironolactone, morphine, and
nitroglycerin) to treat hypervolemia.
 Monitor for therapeutic effects of medications (e.g.,
increased urine output, decreased CVP, decreased
adventitious breath sounds) to assess response to
treatment.
 Monitor potassium levels after diuretic medications to
detect hypokalemia.
 Weigh patient daily and monitor trends to evaluate
effect of treatment.
 Monitor intake and output to assess fluid status.
 Monitor respiratory pattern for symptoms anxiety, air
hunger, orthopnea, dyspnea, tachypnea, cough, frothy
sputum production, and SOB to detect signs and
symptoms of pulmonary edema.
 Monitor hemodynamic status, including HR, BP,
MAP, PAP, PAWP, CO, and CI, if available, to
evaluate effectiveness of therapy.
 Monitor adventitious breath sounds, adventitious heart
sounds, JVD, and peripheral edema to assess response
to treatment.

Copyright © 2020 by Elsevier, Inc. All rights reserved.

eNursing Care Plan 34-4

Nursing Diagnosis
Activity Intolerance
Etiology: Imbalance between O2 supply and demand secondary to cardiac insufficiency
and pulmonary congestion
Supporting data: Dyspnea, shortness of breath, weakness, increase in heart rate on
exertion, patient’s statement, “I am too tired to get out of bed; I have no energy”

Patient Goal
Achieves a realistic program of activity that balances physical activity with energy-
conserving activities

Outcomes (NOC) Interventions (NIC) and Rationales

Activity Tolerance Energy Management
 Pulse rate with activity ___  Encourage alternating rest and activity periods to
 O2 saturation with activity reduce cardiac workload and conserve energy.
___  Provide calming diversionary activities to promote
 Respiratory rate with relaxation to reduce O2 consumption and to relieve
activity ___ dyspnea and fatigue.
 Systolic BP with activity  Monitor patient’s O2 response (e.g., pulse rate, cardiac
___ rhythm, and respiratory rate) to self-care or nursing
 Diastolic BP with activity activities to determine level of activity that can be
___ tolerated.
 Ease of breathing with  Teach patient and caregiver techniques of self-care
activity ___ (e.g., self-monitoring and pacing techniques for
 Ease of performing ADLs performance of ADLs) to minimize O2 consumption.
___
 Skin color ___ Activity Therapy
 Collaborate with occupational and/or physical
Measurement Scale therapists to plan and monitor activity or exercise
1 = Severely compromised program.
2 = Substantially compromised  Determine patient’s commitment to increasing
3 = Moderately compromised frequency and/or range of activities or exercise to
4 = Mildly compromised provide patient with obtainable goals.
5 = Not compromised
ADLs, Activities of daily living; BP, blood pressure; CI, cardiac index; CO, cardiac
output; CVP, central venous pressure; I/O, intake and output; HF, heart failure; HR, heart
rate; JVD, jugular venous distension; MAP, mean arterial pressure; O2, oxygen; PaCO2,
partial pressure of carbon dioxide; PaO2, partial pressure of O2 in arterial blood; PAP,
pulmonary artery pressures; PAWP, pulmonary artery wedge pressure; SOB, shortness of
breath.

Copyright © 2020 by Elsevier, Inc. All rights reserved.